HomeMy WebLinkAbout12-17-12
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
PETITION FOR PROBATE AND GRANT OF LETTERS
Estateot Pauline S. Jacoby , Deamsad ESTATE NO: 21-
a/k/a:
a/k/a:
a/k/a: SSNO: 216-46-4929
Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as
applicable:
El A. Probate and Grant of Letters Testamentaryor❑Administration c.t.a., ord.b.n.c.t.a. (aofr#etePart Ca/sn)
and aver that Petitioner(s) is/are entitled to the aforementioned Letters Testamentary under
the last Will of the above-named Decedent, dated 2 / 7 / 91 and codicil(s) dated
(State relevant circumstances, e.g. renunciation, death of executor, etc.)
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the
instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a
party toa pending divorce proceeding at thetimeof death wherein groundsfor divorce had been established asdefined in
23 Pa. C.&A. § 3323(g): NIA
❑ B. Grant d Lettersd Administration
(If applicable; enter db.rt., pendent lit duranteabsu tia, duranteminoritate)
C. Petitioner(s), after a proper search, has/have ascertained that Decedent left no Will and was survived by
following spouse (if any) and heirs (If Administration c.t.a. or d.b.n.c.t.a., enter date of Will in ction A arfii:zomj4t1 t of
heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was party t>ma pandiag divorce
proceeding wherein grouncisfor divorce had been established asprovided in 23 Pa. C.S PWWW),'eptii Bows:-
Name Address r ~t LT! datieltshi beoedertt~
Cn
t
CZ)
USE ADDITIONAL SHEETSIF NECESSARY
TH I S SECTI ON M UST BE COM PLETED:
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence
At 4 Moore Circle, Carlisle, South Middleton Township, PA
(Street address with Post Office and Zip Code, Municipality: Township, Borough, City)
Decedent, then 93 years of age, died December 9 , 2 01dt Carlisle, PA
(Month, Day, Year of death) (City and State where death occurred)
Estimated value of decedent's property at death:
If domiciled in PA All personal property $ 500,000.00
If not domiciled in PA Personal property in Pennsylvania $
If not domiciled in PA Personal property in County $
-Value of Real Estate in Pennsylvania $ 200,000.00
Total Estimated Value $ 7 0 0, 0 0 0.0 0
Location of Real Estate in Pennsylvania: (Provide full address if possible.)
Signature( Name(s) & Mailing Addres (es)
,,,(,w 1 Zpl Lowell E. Jacoby
815 North Alfred Street
Alexander, Virginai 22314
Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page I of 2
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORDED OFFICIF OF
Fee for this certificate, $6.t E~+~s t! t(! h(~ i, to ccrtit%- that the information here i,iven is
+ "c - pF ._(,rrccik copied from an ori-inal Certificate of Death
(f
~ loe filets v,'~ith me as Local Registrar. The original
ZR10~2 DEC 17 PM i 1 11- c( tif)_ate will he for~iarded to the State Vital
le~,l - z,c R -c:;rds Ot'fi c: C0r permanent fifing.
CLERK OF 41
P 18 8 8 413R$HANs' cO
gw~K orb 10/2012
Certification NLIMI jMBERLAND CO., P i,O al Rvgistran Date Issued
5
Type/Print In COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF HEALTH - VITAL RECORDS
Permanent: CERTIFICATE OF DEATH
Bl
ack Ink Number:
State
File
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sez 3. Social Security Number 4. Date of Death (MO/Day/yr) (Spell Mo)
Pauline E_ Jacob Femal 216-46-4929 December 9, 2012
Sa. Age-Last Birthday (Yrs) 56. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/Day/y"r) (Spell Month) 17- Birthplace (City and Stare or Foreign Country)
93 Months Days Hours Minutes July 5 , 1919 ink
7b. Birthplace (County)
8a. Residence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.) 8,j(c. Dld Decedent Live in a Township?
PA 4 Moore Circle L'lyes, decedent $Ned In South Middleton ty„p.
gd. Residence (County)
Cumberland Be. Residence (Zip Code) 17015 0 No, decedent lived within limits of city/b.--
9. Ever In US Armed Forces? 30. Marital Status at Time of Death Q Married Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Q Yes aa No E3 Unknown Divorced Never Married Unknow
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Frank S,= Viola C_ H_ Hartman
14a. Informant's Name 114. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code)
Wanda Lord-Steele daughter 6707 white Post Road, Centreville, VA 2012
0
G -•--------.-...----..---.........---------'--.....lsa_ P ace o Deat.-- C ec on Y one
w.
ed Some -her.--...he....................
s eat rge a in a Hospital: Inpatient :If Death Ocuc re Other Than Hospital: i_I Hospice Facility Decedent's Home
o Q Emergency Room/Outpatient 0 Dead on Arrival
0 Nursinrrg Home/Long-Term Care Facility Q Other (Specify)
ad 156. Faclli Name jIf not I titution,gIv e street and number; 16c. City or TQ State, Pd A ode 15d. County of Death
4 Moore Circe Carlisle, PA 1C7015 Cumberland
LL 16a. Method of Disposition] Burial 0 Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
p Removal from State p Donation Dec 12 , 2012 Longsdorf Cemetery
Other (Spec) fy)
16d. Location of Disposition (City or Town, Stale, and Zip) 17a. Slg of Fu(ner e Ice Llcens ee or Person in Charge S. of Interment 17b. License Number
New Kingstown, PA 17072 013144E
c 17c. Name antl Complete Address of Funeral Facility
Hoffman-Roth Funeral Home & Cremat , 219 North Hanover Street, Carlisle, PA 17013
18. Decedent's Education - Check the box that best describes the 19. Decedent of Hispanic Origin - Check the 2D. Decedent's Race - Check ONE OR MORE races to Indicate what
i- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to -be.
0 8th grade or less Spanish/Hispanic/Latino. Check the "No" White 0 Korean
E3 Nigho dlploma, 9th - 12th grade ~x If decedent is not Spanish/Hispanic/Latino. Q Black or African American Vietnamese
H school graduate or GED completed No, not Spanish/Hlspa nlc/LaTlno Q American Indian or Alaska Native Other Asian
Ej Some college credit, but no degree C3 Yes, Mexican, Mexican American, Chicano 0 Asian Indian C3 Native Hawaiian
0 Associate degree (e.g. AA, AS) Yes, Puerto Rican Chl nase
0 0 Guamanian or Chamorro
Bachelor's degree (e.g. BA, AS, BS) 0 Yes, Cuban E3 Filipino 0 Samoan
0 Master's degree (e.g. MA, MS, MEng, MEd, -SW, MBA) Yes, the, Spanish/Hispanic/Latino E3 Japanese 0 Other Pacific Islander
E3 Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) Other (S
. MD DDS DVM, LLB, JD pecify)
23. De ceden['s Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of work
Whl[e 0 Japanese Samoan done during most of working life. DO NOT USE RETIRED.
E:3 Black or African American Ej Korean 0 Other Pacific Islander Homemaker
p American Indian or Alaska Native Q Vietnamese
0 0 Don't Know/Not Sure
~i C] Asian Indian 0 Other Asian E3 Refused 22b. Kind of Business/industry
Q Chinese Q Native Hawaiian Q Other (Specify)
O Filipino O Guama=na,Chamorro Own Home
ITEMS 23a - 237 MUST BE COMPLETED Be- 2Data Pronounced Dead (MO/Day r) 23b. Signature of Person Pronouncing Death
BY PERSON WHO PRONOUNCES OR (Only when applicable) 23c. License Number
CERTIFIES DEATH
23d. Date Signed (MO/Day/V r) 24. Time of Death
L.TnknOWn 25. Was Medical Examiner or Coroner Contacted? Yes E3 No
CAUSE OF DEATH
Approximate
26. Part 1. Enter the chain of events--diseases, Injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval:
respiratory arrest, or ventricular fibrillatio/n/,~{wI `/ltho t showing the erlolo~g/y'. DO NO A BR ~V,IA/TE. Enter only one cause on a Ilne. Add additional lines if necessary Onset to Death
IMMEDIATE CAVSE a. ! V oe owd %/llll/
(Final disease or pond Rion Dt,e to (or as a won ~a
rests Ming I. death) seq~en of):
b.
Sequentially list conditions, Due to (or as a consequence of):
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
ffi (disease or injury that
G Initiated the events resulting d.
In death) LAST. Due to (or as a consequence of):
26. Part 11. Enter other significant conditions contribut'n to death but not resulting in the underlying cause given in Part I 27. Was an autopsy pe,,~~r.f,or~~med?
~ Q Yes I~Y1Vp
28. Ware autopsy f(ndl ngs available
m to complete the cause of death?
Q Yes
29. If Female: 30. Did Tobacco Use Contrlbute to Death? 31. Manner of Death
o _M~NOt pregnant within past year M Yes P,.babl
Homicide
0 Pregnant at time of death $'fJO 0 Unknown tX"atural r3
m C3 Not pregnant, but pregnant within 42 days of death O Accident ~ Could not be determined
C3 Not pregnant, but pregnant 43 days to 1 year before cl- 32. Date of Injury (M./Da/Y, 5 Suicide Q Could not be determned
y ) ( pelt Month)
Unknown If pregnant w(thln [he past yeas 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
Q Yes E3 Driver/Operator E3 Pedestrian
0 No 0 Passenger Q Other(Specify)
39a. Certifier (Check only one):
Eertifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated
Pronouncing & Certifying phy ician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated
Medical Examiner/CoronSer~- On~tFQ~/Qra is f ex 1 a~tl~on/,~ nd~/o Inve tigation, In my opinion, death o rred at the time, date, and place, and due to the cause( ) d a neer stated
Signature of certifier: Cl D h6lJr~/A Tltle of certifier: M- D- Ucensa Number: MD O I R 3' l G
39b. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) DONALD J. KOYACS, AND 39c. Date Signed (MO/Day/Yr)
Yellow Broaone: Femirv fraction tamer
b O 3P I L
t 1358 LWxiown Rd.. Boiling $pnngs. IP
PA 1)007-
L`. 40. Registrar's District Number 41. Registrar'~g+ 42. Registrar File Oate (MO Oay/Yr
~ O
43. Amendments
o_
$a
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-143
Disposition Permit No. O (t't t~ tJ~O 'HIOS
07/2 11
G Q M C.)
M C>
;a t- LAST WILL AND TESTAMENT
Or r7_
PAULINE S. JACOBY rv
r
I, PAULINE S. JACOBY, a resident of 246 East Old York Road,
Carlisle, Cumberland County, Pennsylvania being of sound mind,
memory and understanding, do hereby make, publish and declare this
to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
ITEM 1: I direct that all my just debts, the expenses of my
last illness and funeral expenses be paid as soon after my decease
as the same can conveniently be done.
ITEM 2: I direct that there shall be paid out of my
residuary estate all estate, inheritance and like taxes together
with any interest or penalty thereon imposed by the government of
the United States, or any state or territory thereof, or by any
foreign government or political subdivision thereof, in respect to
all property required to be included in my gross estate for
estate, inheritance or like tax purposes by any of such govern-
ments, whether the property passes under this Will or otherwise,
excluding, however, any property over which I have a taxable power
of appointment, provided, however, that no residuary beneficiary
shall by reason of this provision be denied the benefit of any
deduction, credit, favorable rate of tax or other benefit which by
law enures to such beneficiary.
t
PAULINE S. JACOO J,
v
-1-
LAST WILL AND TESTAMENT
OF
PAULINE S. JACOBY
ITEM 3: I give, devise and bequeath all of the rest,
residue and remainder of my estate, real, personal and mixed, of
whatsoever kind and nature, and wheresoever situate at the time of
my death, in equal shares, unto my children, LOWELL E. JACOBY,
WANDA J. LORD, and SOPHIE J. KOWZUN, provided, however, that they
survive me and are living sixty (60) days after the date of my
death.
ITEM 4: If and in the event that a child of mine does not
survive me and is not living sixty (60) days after the date of my
death, then and in such event, I give, devise and bequeath the
interest in my estate, which such deceased child would have
received, if living, to the issue of said deceased child, per
sti.rpes.
ITEM 5: If and in the event that my son, LOWELL E. JACOBY,
dies without issue, then and in such event, I give, devise, and
bequeath the interest in my estate, which he would have received,
if living, in equal shares, unto my other children, then living.
ITEM 6: I hereby nominate, constitute and appoint my son,
LOWELL E. JACOBY, Executor of this my Last Will and Testament,
with full power to do any and all things necessary for the
complete administration of my estate, and direct that no bond or
other surety is required of him in this or any other jurisdiction
for his performance of this office.
_Z- PAULINE S. JAC`BY
LAST WILL AND TESTAMENT
OF
PAULINE S. JACOBY
If and in the event that my son, LOWELL E. JACOBY, does not
survive me and is not living sixty (60) days after the date of my
death, or does not complete his duties as Executor, then and in
such event, I hereby nominate, constitute and appoint my daughter,
WANDA J. LORD, Executrix of this my Last Will and Testament, with
full power to do any and all things necessary for the complete
administration of my estate, and direct that no bond or other
surety is required of her in this or any other jurisdiction for
her performance of this office.
ITEM 7: If any provision of this Will or of any Codicil
hereto is held to be inoperative, invalid or illegal, it is my
intention that all the remaining provisions thereof shall continue
to be fully operative and effective, so far as is possible and
reasonable.
IN WITNESS WHEREOF, I, PAULINE S. JACOBY, the Testatrix, have
to this my Last Will and Testament, typewritten on four (4)
consecutively numbered pages, subscribed my name and affixed my
seal this 7,& day of February, 1991.
j~ (SEAL)
P ULINE S. JACOffy
-3-
LAST WILL AND TESTAMENT
OF
PAULINE S. JACOBY
Signed, sealed, published and declared by the above named
Testatrix, as and for her Last Will and Testament, in the presence
of us, who have hereunto subscribed our names at her request, as
witnesses hereto, in the presence of the said Testatrix, and of
each other.
"'esiding at
residing at
Cl/
-4-
OATH OF SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
Estate of PAULINE S. JACOBY Deceased
_ AntthnnW T.- Dg-T.11c-a, F.c Till YP , (each) a subscribing witness to
(Print Names)
the Ej Will D Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and
say(s) that she / he / they was / were present and saw the above Testator / Testatrix sign the same
and that she / he / they signed the same and that she / he / they signed as a witness at the request of
the Testator / Testatrix in her / his presence and in the presence of each other.
CIO e iTl
(Signature) (Signature) X ~U
C-D Vt)
M C'> rt~
(Street Address) (Street Address)
49.0 Ir7 Q -P
(City, State, Zip) (City, State, Zip) C
a
F" r-
F-+
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Sworn to or affirmed and subscribed
before me this day before me this day
of ~~CL1FJ~ of ,
L47K~- 4b,'L_
eputy for Register ills Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization.
Form RW-03 rev. 10.13.06
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 21-
Estate of~j ~u t° S • ~T~ ~o Deceased
UNAVAILABLE WITNESS AFFIDAVIT
I, w , a being duly sworn according to law, depose and say
that I, the g A torney ❑ Personal Representative in the above referenced Estate, declare that
and
whose signature(s) appears as subscribing witness(es) to the 4 Will or ❑ Codicil of the above
Testator is/are not readily available to prove the signature to the Testator by reason of
n L n tiG"cam P_e~/
Sworn to or affinned and subscribed GP
Before me t 's day of Signature of Coun er@nal Repres8~atiyT I'M"'
w LYE 20.
rn n try
rn C->
m ~.Y r+
Jta :
Q'eepnutyv for Register i s c~ _71 ...~.1
(Must sign in Re ' ter's ffice) -
OATH OF NON-SUBSCRIBING WITNESS
~6'GtJP~~ ~ • ~c1~ b~ and
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that
he is/she is/they are familiar with the signature of the above Testator of the Will or ❑ Codicil
presented herewith and that he/she/they believe(s) the signature on the,1 Will or ❑ Codicil is in
the handwriting of the above Testator to the best of his/her/their knowledge and belief.
Sworn to or affirmed and subscribed La .A
Before me this ~ day of Signature of Non- ubscri g Witness
LIZ A 20
' Signature of Non-Subscribing Ilitness
eputy for Register of Wills
(Must sign in Register's Offs e